On Tue, 1 Apr 2008 18:11:54 -0800, "Superman Hughes Troll, Top s***
bag and Usenet Queen" <BillHughes@[EMAIL PROTECTED]
> wrote:
Personality disorders are pervasive, inflexible, and stable patterns
of behavior that cause significant distress or functional impairment.
Ten distinct personality disorders have been identified and grouped
into 3 clusters. All are believed to be caused by a combination of
genetic and environmental factors. Diagnosis is clinical. Treatment is
with psychotherapy and sometimes drug therapy.
Personality traits are patterns of thinking, perceiving, reacting, and
relating that are relatively stable over time and in various
situations. Personality traits are usually evident from late
adolescence or early adulthood, and although many traits persist
throughout much of life, some fade with aging and some can be
modified. Personality disorders exist when these traits become so
rigid and maladaptive that they impair functioning. Mental coping
mechanisms (defenses) that are used unconsciously at times by everyone
tend to be immature and maladaptive in people with personality
disorders
People with personality disorders are often frustrating and even
infuriating to people around them (including physicians). Most are
distressed about their lives and have impaired work or social
relation****ps. Personality disorders often coexist with mood, anxiety,
substance abuse, and eating disorders. People with severe personality
disorders are at high risk of hypochondriasis and violent or
self-destructive behaviors. They may have inconsistent, detached,
overemotional, abusive, or irresponsible styles of parenting, leading
to physical and mental problems in their children.
About 13% of the general population is affected. Antisocial
personality disorder occurs in about 2%, with men outnumbering women
6:1. Borderline personality disorder occurs in about 1%, with women
outnumbering men 3:1.
Classification
The Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition Text Revision (DSM-IV-TR) recognizes 10 distinct personality
disorders and divides them into 3 clusters:
A: Odd/eccentric
B: Dramatic/erratic
C: Anxious/fearful
Cluster A: Patients tend to be detached and distrustful.
Paranoid personality involves coldness and distancing in
relation****ps, with a need for control and a tendency toward jealousy
if attachments are formed. Affected people are often secretive and
untrusting. They tend to be suspicious of changes and frequently find
hostile and malevolent motives behind other people's acts. Often,
these hostile motives represent projections (see Table 1: Personality
Disorders: Coping Mechanisms) of their own hostilities onto others.
Their reactions sometimes surprise or scare others. They then use the
resulting anger of or rejection by others (ie, projective
identification) to justify their original feelings. Paranoid people
tend to feel a sense of righteous indignation and often take legal
action against others. These people may be highly efficient and
conscientious, although they usually need to work in relative
isolation. This disorder must be differentiated from paranoid
schizophrenia.
Schizoid personality is characterized by introversion, social
withdrawal, isolation, and emotional coldness and distancing. Affected
people are often absorbed in their own thoughts and feelings and fear
closeness and intimacy with other people. They are reticent, are given
to daydreaming, and prefer theoretical speculation to practical
action.
Schizotypal personality, like schizoid personality, involves social
withdrawal and emotional coldness but also includes oddities of
thinking, perception, and communication, such as magical thinking,
clairvoyance, ideas of reference, or paranoid ideation. These oddities
suggest schizophrenia (see Schizophrenia and Related Disorders:
Schizophrenia) but are never severe enough to meet its criteria.
People with schizotypal personality are believed to have a muted
expression of the genes that cause schizophrenia.
Cluster B: Patients tend to be emotionally unstable, impulsive, and
intense.
Borderline personality is marked by unstable self-image, mood,
behavior, and relation****ps. Affected people tend to believe they were
deprived of adequate care during childhood and consequently feel
empty, angry, and entitled to nurturance. As a result, they
relentlessly seek care and are sensitive to its perceived absence.
Their relation****ps tend to be intense and dramatic. When feeling
cared for, they appear like lonely waifs who seek help for depression,
substance abuse, eating disorders, and past mistreatments. When they
fear the loss of the caring person, they frequently express
inappropriate and intense anger. These mood ****fts are typically
accompanied by extreme changes in their view of the world, themselves,
and other people—eg, from bad to good, from hated to loved. When they
feel abandoned, they dissociate or become desperately impulsive. Their
concept of reality is sometimes so poor that they have brief episodes
of psychotic thinking, such as paranoid delusions and hallucinations.
They often become self-destructive and may cut themselves
(self-mutilate) or attempt suicide. They initially tend to evoke
intense, nurturing responses in caretakers, but after repeated crises,
vague unfounded complaints, and failures to comply with therapeutic
recommendations, they are viewed as help-rejecting complainers.
Borderline personality tends to become milder or to stabilize with
aging. (See also the American Psychiatric Association's Guideline
Watch: Practice Guideline for the Treatment of Patients With
Borderline Personality Disorder.)
Antisocial personality is marked by the callous disregard for the
rights and feelings of other people. Affected people exploit others
for materialistic gain or personal gratification. They become
frustrated easily and tolerate frustration poorly. Characteristically,
they act out (see Table 1: Personality Disorders: Coping Mechanisms)
their conflicts impulsively and irresponsibly, sometimes with
hostility and violence. They usually do not anticipate the
consequences of their behaviors and typically do not feel remorse or
guilt afterward. Many of them have a well-developed capacity for
glibly rationalizing their behavior or blaming it on others.
Dishonesty and deceit permeate their relation****ps. Punishment rarely
modifies their behavior or improves their judgment. Antisocial
personality often leads to alcoholism, drug addiction, promiscuity,
failure to fulfill responsibilities, frequent relocation, and
difficulty abiding by laws. Life expectancy is decreased, but the
disorder tends to diminish or stabilize with aging.
Narcissistic personality involves grandiosity. Affected people have an
exaggerated sense of superiority and expect to be treated with
deference. Their relation****ps are characterized by a need to be
admired, and they are extremely sensitive to criticism, failure, or
defeat. When confronted with a failure to fulfill their high opinion
of themselves, they can become enraged or seriously depressed and
suicidal. They often believe other people envy them. They may exploit
others because they think their superiority justifies it.
Histrionic personality involves conspicuous attention seeking.
Affected people are also overly conscious of appearance and are
dramatic. Their expression of emotions often seems exaggerated,
childish, and superficial. Still, they frequently evoke sympathetic or
*****c attention from other people. Relation****ps are often easily
established and overly ***ualized but tend to be superficial and
transient. Behind their seductive behaviors and their tendency to
exaggerate somatic problems (ie, hypochondriasis) often lie more basic
wishes for dependency and protection.
Cluster C: Patients tend to be nervous and passive or rigid and
preoccupied.
Dependent personality is characterized by the surrender of
responsibility to other people. Affected people may submit to others
to gain and maintain sup****t. For example, they often allow the needs
of people they depend on to supersede their own. They lack
self-confidence and feel intensely inadequate about taking care of
themselves. They believe that others are more capable, and they are
reluctant to express their views for fear that their aggressiveness
will offend the people they need. Dependency in other personality
disorders may be hidden by obvious behavioral problems; eg, histrionic
or borderline behaviors mask underlying dependency.
Avoidant personality is marked by hypersensitivity to rejection and
fear of starting relation****ps or anything new because of the risk of
failure or disappointment. Because affected people have a strong
conscious desire for affection and acceptance, they are openly
distressed by their isolation and inability to relate comfortably to
other people. They respond to even small hints of rejection by
withdrawing.
Obsessive-compulsive personality is characterized by
conscientiousness, orderliness, and reliability, but inflexibility
often makes affected people unable to adapt to change. They take
responsibilities seriously, but because they hate mistakes and
incompleteness, they can become entangled with details and forget
their purpose. As a result, they have difficulty making decisions and
completing tasks. Such problems make responsibilities a source of
anxiety, and they rarely enjoy much satisfaction from their
achievements. Most obsessive-compulsive traits are adaptive, and as
long as they are not too marked, people who have them often achieve
much, especially in the sciences and other academic fields in which
order, perfectionism, and perseverance are desirable. However, they
can feel uncomfortable with feelings, interpersonal relation****ps, and
situations in which they lack control, they must rely on other people,
or events are unpredictable.
Other personality types: Several other personality types have been
described but are not classified as disorders in the DSM-IV-TR.
Passive-aggressive (negativistic) personality typically produces the
appearance of ineptness or passivity, but these behaviors are covertly
designed to avoid responsibility or to control or punish other people.
Passive-aggressive behavior is often evidenced by procrastination,
inefficiency, or unrealistic protests of disability. Frequently,
affected people agree to do tasks they do not want to do and then
subtly undermine completion of the tasks. Such behavior usually serves
to deny or conceal hostility or disagreements.
Cyclothymic personality (see also Mood Disorders: Cyclothymic
Disorder) alternates between high-spirited buoyancy and gloomy
pessimism; each mood lasts weeks or longer. Characteristically, the
rhythmic mood changes are regular and occur without justifiable
external cause. When these features do not interfere with social
adaptation, cyclothymia is considered a temperament and is present in
many gifted and creative people.
Depressive personality is characterized by chronic moroseness, worry,
and self-consciousness. Affected people have a pessimistic outlook,
which impairs their initiative and disheartens other people.
Self-satisfaction seems undeserved and sinful. They unconsciously
believe their suffering is a badge of merit needed to earn the love or
admiration of others.
Diagnosis
Specific personality disorders are diagnosed based on DSM-IV-TR
criteria. The general criteria in DSM-IV-TR emphasize the need to
consider whether other mental or physical disorders (eg, depression,
substance abuse, hyperthyroidism) can account for the patient's
patterns of behavior.
Patients' emotional reactions and their perspectives on what causes
their problems and how other people treat them can provide information
about their disorder. Diagnosis is based on observing repetitive
patterns of behavior or perceptions that cause distress and impair
social functioning. Because the patient often lacks insight into these
patterns, physicians may initially seek information from and
evaluation by others who interact with the patient. Often, physicians
suspect a personality disorder based on their own discomfort,
typically if they begin to feel angry or defensive.
Treatment
Although treatment differs according to the type of personality
disorder, some general principles apply:
Family members and friends can act in ways that either reinforce or
diminish the patient's problematic behavior or thoughts; thus, their
involvement is helpful and often essential.
An early effort should be made to get patients to see that the problem
is really based on who they are.
Treating a personality disorder takes a long time; repetitious
confrontation in prolonged psychotherapy or by peer encounters is
usually required to make patients aware of their defenses, beliefs,
and maladaptive behavior patterns.
Because personality disorders are particularly difficult to treat,
therapists need experience, enthusiasm, and an understanding of the
patient's expected areas of emotional sensitivity and usual ways of
coping. Kindness and guidance alone do not change personality
disorders. Treatment may involve a combination of psychotherapy and
drug therapy. However, symptoms typically are not very responsive to
drugs.
Relief of anxiety or depression is the first goal, and drug therapy
can be helpful. Reducing environmental stress can also quickly relieve
such symptoms
Maladaptive behaviors, such as recklessness, social isolation, lack of
assertiveness, or temper outbursts, can be changed in months. Group
therapy and behavior modification, sometimes within day hospital or
residential settings, are effective. Participation in self-help groups
or family therapy can also help change socially undesirable behaviors.
Behavioral change is most im****tant for patients with borderline,
antisocial, or avoidant personality disorder. Dialectical behavioral
therapy (DBT) is effective for borderline personality disorder. DBT,
which involves weekly individual psychotherapy and group therapy as
well as telephone contact with therapists between scheduled sessions,
seeks to help patients understand their behaviors and teach them
problem solving and adaptive behaviors. Psychodynamic therapy is
effective for patients with borderline and avoidant personality
disorders. Such therapies help patients with personality disorders
reorganize feeling states in themselves and think about the effect
their behaviors have on other people.
Interpersonal problems, such as dependency, distrust, arrogance, and
manipulativeness, usually take > 1 yr to change. The cornerstone for
effecting interpersonal changes is individual psychotherapy that helps
patients understand the sources of their interpersonal problems. A
therapist must repeatedly point out the undesirable consequences of
the patient's thought and behavior patterns and must sometimes set
limits on the patient's behavior. Such therapy is essential for
patients with histrionic, dependent, or passive-aggressive personality
disorder. For some patients with personality disorders that involve
how attitudes, expectations, and beliefs are mentally organized (eg,
narcissistic or obsessive-compulsive types), psychoanalysis is
recommended, usually for = 3 yr.
--
“A winner makes commitment. A loser makes promises.”
“The path of least resistance is the path of the loser.”
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